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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O L 1, —CITY/ZIP— <br /> - <br /> ITY/ZIP <br /> �J y <br /> CROSS STREET yL APN 7U -j /PJARCEL SIZE /� p <br /> OWNER NAME 1 6%d.'tl Cf' �7 j/1 • — PHONE L 04rI/�' 62 3) 3-�,"t <br /> OWNER ADDRESS `}.� a�L {1.� CITY/STATE/ZIP <br /> /� /_ �Vw )y,/ <br /> �] <br /> CONTRACTOR Y& '` L�n J7"�h'q`)'� PHONE .1 D`I 6 7f4 ./-/ <br /> 0 <br /> CONTRACTOR ADDRESS 7� C) Sox /(i Ci CITY/STATE/ZIP e n/, <br /> LICENSE 1-7C-42 ❑-C-36 OTHER NUMBER -- 56 L EXPIRATION DATE .7�! z t,r <br /> WATER TABLE DEPTH: 1 0_`S O It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: _ NEW INSTALLATION REPAIR/ADDITION _ ENGINEER DESIGNED/{�L/TERNATIVE <br /> REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION fCi y f` <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: I /"� NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 1 n VI,,p W�JC & CAPACITY I�y gal #OF COMPARTMENTS V <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY +� gal #OF COMPARTMENTS r <br /> DISTANCE TO NEAREST: WELL I b&t- ft FOUNDATION `U It PROPERTY LINE ,]Cl It <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> CL LEACH LINES C LEACHING CHAMBERS n;� #OF LINES LENGTH OF LINES too ft <br /> DISTANCE TO NEAREST WELL JO It FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTERBED WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI 48 11011R ADVANCE NOTICE REQUIRED FOR/NSP TIONS-PLEASE CALL 209 953-769 <br /> SIGNED TITLE ✓PI��- DATE_ Z-'� Z r <br /> r <br /> r <br /> PAY EI <br /> REC <br /> JAN 22 <br /> SAN JOAQU( T <br /> ENVIRON <br /> HEALTH DEP <br /> DEPARTMENT USE ONLY <br /> Application Accepted By v� Date 3d ' ) Area S 1 Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th^'3 Ft: Piti p Soil Character: <br /> COMMENTS 1, ,F)Vyf�r+hj 5j," (lfctj},)� lrr�[h I��e/ v�,l,'c ►�� pr <br /> PE SC R <br /> Service Re Received Amount Date Pe Req # Invoice# Permit ID# <br /> Code INFO Remitted <br /> Lia 10 11 -D 11sSINgg <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />